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(BQ) Part 1 book Lung ultrasound in the critically Ill has contents: An introduction to the signatures of lung ultrasound, the pleural line, pneumothorax and the a’ profile, the blue protocol, venous part - deep venous thrombosis in the critically ILL, technique and results for the diagnosis of acute pulmonary embolism,... and other contents.
Daniel A Lichtenstein Lung Ultrasound in the Critically Ill The BLUE Protocol 123 Lung Ultrasound in the Critically Ill Daniel A Lichtenstein Lung Ultrasound in the Critically Ill The BLUE Protocol Daniel A Lichtenstein Hôpital Ambroise Paré Service de Réanimation Médicale Boulogne (Paris-West University) France ISBN 978-3-319-15370-4 ISBN 978-3-319-15371-1 DOI 10.1007/978-3-319-15371-1 (eBook) Library of Congress Control Number: 2015941278 Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2016 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com) “The lung: a major hindrance for the use of ultrasound at the thoracic level.” TR Harrison Principles of Internal Medicine, 1992, p 1043 “Ultrasound imaging: not useful for evaluation of the pulmonary parenchyma.” TR Harrison Principles of Internal Medicine, 2011, p 2098 “Most of the essential ideas in sciences are fundamentally simple and can, in general, be explained in a language which can be understood by everybody.” Albert Einstein The evolution of physics, 1937 “Le poumon…, vous dis-je !” (The lung… I tell you!) Molière, 1637 (continued) These extracts were introducing the Chapter on lung ultrasound of our 2005 Edition The present textbook is fully devoted to this application A ma famille, mes enfants, le temps que je leur consacré était en concurrence avec ces livres qui ont aussi été ma vie Trouver l’équilibre entre une vie de famille idéale et la productivité scientifique a été un défi permanent Les défauts qu’on pourra trouver dans le présent ouvrage ne seront dûs qu’à une faiblesse dans la délicate gestion de cet équilibre Mon père n’aurait pas cru, en 1992, époque de la première édition, qu’il verrait celle-ci; cet ouvrage lui est dédié Ma mère sera heureuse de voir d’en haut cet achèvement d’une vie A Joëlle Our life is a gift from God; what we with that life is our gift to God Contents Part I The Tools of the BLUE-Protocol Basic Knobology Useful for the BLUE-Protocol (Lung and Venous Assessment) and Derived Protocols Preliminary Note on Knobology Which Setting for the BLUE-Protocol? Which Setting for the Other Protocols (FALLS, SESAME, etc.) and Whole Body Critical Ultrasound? Step 1: The Image Acquisition Step 2: Understanding the Composition of the Image Step 3: Image Interpretation References Which Equipment for the BLUE-Protocol? (And for Whole-Body Critical Ultrasound) – The Unit The Seven Requirements We Ask of an Ultrasound Machine Devoted to Critical Care – A Short Version for the Hurried Reader A Longer Version: The Seven Requirements We Ask of an Ultrasound Machine Devoted to Critical Care The Coupling System: A Detail? Data Recording How to Practically Afford a Machine in One’s ICU What Solutions Are There for Institutions Already Equipped with Laptop Technologies? Which Machines for Those Who Work Outside the Hospital and in Confined Space? The Solution for the Future Some Basic Points and Reminders Appendix 1: The PUMA, Our Answer to the Traditional Laptops References Which Equipment for the BLUE-Protocol The Probe The Critical Point to Understand for Defining the “Universal Probe” in Critical Care: The Concept of the Providential (Optimal) Compromise 11 12 12 17 18 18 19 19 20 21 21 22 23 23 vii Contents viii How to Scientifically Assess This Notion of “Domain of Interpretability”? Our High-Level Compromise Probe Why Is Our Microconvex Probe Universal The Strong Points of Having One Unique Probe The Usual Probes of the Laptop Machines Some Doctors Prefer to Swap the Probes for Each Application, and Not Use the Universal Probe Why? Pericardial Tamponade: Time for a Nice Paradox, Just One Illustration of What is “Holistic Ultrasound” What to Say to Those Who Still Have Only the Three Usual Probes? An Unexpected (Temporary) Solution? Important Notes Used as Conclusion Reference How We Conduct a BLUE-Protocol (And Any Critical Ultrasound): Practical Aspects Disinfection of the Unit: Not a Futile Step When Is It Time to Perform an Ultrasound Examination Since When Do We Perform These Whole-Body Ultrasound Examinations: Some Historical Perspectives References The Seven Principles of Lung Ultrasound Development of the First Principle: A Simple Method Development of the Second Principle: Understanding the Air-Fluid Ratio and Respecting the Sky-Earth Axis The Third Principle: Locating the Lung and Defining Areas of Investigation The Fourth Principle: Defining the Pleural Line The Fifth Principle: Dealing with the Artifact Which Defines the Normal Lung, the A-Line The Sixth Principle: Defining the Dynamic Characteristic of the Normal Lung, Lung Sliding Development of the Seventh Principle: Acute Disorders Have Superficial, and Extensive, Location Reference The BLUE-Points: Three Points Allowing Standardization of a BLUE-Protocol The Concept of the BLUE-Hands Lung Zones, Their Relevance in the BLUE-Protocol, Their Combination with the Sky-Earth Axis for Defining Stages of Investigation Some Technical Points for Making Lung Ultrasound an Easier Discipline Standardization of a Lung Examination: The BLUE-Points Standardization of a Lung Examination: The Upper BLUE-Point 25 28 29 31 33 33 34 34 35 35 37 38 42 42 42 45 45 46 47 47 47 47 47 49 51 51 52 53 53 54 Contents ix Standardization of a Lung Examination: The Lower BLUE-Point The PLAPS-Point Location of the Lung in Challenging Patients Other Points? The Case of the Patient in the Prone Position BLUE-Points and Clinical Information Aside Note More Devoted to Pulmonologists Philosophy of the BLUE-Points: Can the Users Do Without? Reference 54 54 56 56 56 57 57 58 An Introduction to the Signatures of Lung Ultrasound The pleural line The A-line Lung sliding 4–7 The quad sign, sinusoid sign, shred sign, and tissue-like sign Lung rockets Abolished lung sliding 10 The lung point Other Signs Note 59 59 59 59 The Pleural Line The Pleural Line: The Basis Standardizing Lung Ultrasound: Merlin’s Space Standardizing Lung Ultrasound: Keye’s Space Standardizing Lung Ultrasound: The M-Mode-Merlin’s Space Reference 61 61 63 63 64 64 The A-Profile (Normal Lung Surface): 1) The A-Line The Artifact Which Defines the Normal Lung Surface: The A-line Note Other Artifacts Some History Reference 65 The A-Profile (Normal Lung Surface): 2) Lung Sliding Lung Sliding: A New Sign, a New Entity in the Respiratory Semiology Normal Lung Sliding in the Healthy Subject, a Relative Dynamic: The Seashore Sign Lung Sliding, Also a Subtle Sign Which Can Be Destroyed by Inappropriate Filters or So-Called Facilities The Importance of Mastering Dynamics and Bypassing These Facilities The Various Degrees of Lung Sliding, Considering Caricaturally Opposed States Lung Sliding in the Dyspneic Patient The Maximal Type Critical Notions Regarding the Mastery of the B/M-Mode 67 10 59 59 59 59 60 60 65 66 66 66 66 67 68 69 69 70 The Developed BLUE-protocol 139 perfect idea, not fully logical, and we prefer to consider the calf veins, an area appearing much more “stable.” There is also a debate between those who argue they can scan the popliteal vein in all supine patients and others who find it difficult Prone positioning, Valsalva maneuvers, etc., are irrelevant in the critically ill patient In spite of these limitations, the users will once again appreciate the holistic power of the BLUEprotocol: we just have to slightly bend the knee, and insert our 88 mm-long microconvex probe 10 The BLUE-protocol Is Done by the First-Line Physician arrest to a simple medical airborne transportation (ULTIMAT-protocol, Chap 33) or the visit at your grandmother who has a slight complaint at the leg (DVT? Simple arthrosis?), the protocol will be applied the same In between, all these settings, the emergency room, with leg pain or all those kinds of troubles, the intensive care unit, routine scan of standstill patients, the ward or geriatric department… can make use of the BLUE-protocol We can here evoke the daily question, in the ER, of the management of a non-critically ill patient suspected with mild pulmonary embolism and with negative venous ultrasound scanning In order to make a homogeneous textbook, this situation is detailed in Chap 36 No comment, read at the beginning of this chapter The Developed BLUE-protocol An Eleventh Point? Definitely The venous BLUE-protocol can be used in multiple settings, without any adaptation It also works in cardiac arrest (Step of the SESAME-protocol, Chap 31) From cardiac All this chapter generates a change in the decision tree As said initially, the short term “venous analysis” is replaced by the current sequence, which results in making the protocol much simpler (Fig 18.20) Anterior Lung sliding any present B profile A profile B’ profile A/B or C profile A’ profile Venous analysis PULMONARY EDEMA The BLUE protocol abolished PNEUMONIA plus lung point PNEUMONIA without lung point common femoral V-point PNEUMOTHORAX calf Fig 18.20 The BLUEprotocol, extension of the venous branch This figure shows the developed item “venous thrombosis.” This makes more items, but less time spent than a comprehensive scanning Need for other diagnosis modalities This decision tree does not aim at providing the diagnosis It indicates a way for reaching a 90.5% accuracy when using lung ultrasound upper axes Free veins Stage Thrombosed vein PLAPS PULMONARY EMBOLISM PNEUMONIA no PLAPS COPD or ASTHMA 140 18 The BLUE-Protocol, Venous Part: Deep Venous Thrombosis in the Critically Ill Limitations of Venous Ultrasound (Reminder) Natural limitations Abdominal gas for iliocaval veins Fat (plethoric patients) for deep veins Natural echogenicity Some patients are more difficult to scan than others Chronic thromboses (see in text, calf veins) Pathological limitations Hypovolemia, when it makes the venous section smaller Artificial limitations Dressing (of catheters) Tracheostomy cord (but see CLOT-protocol in Chap 28) Orthopedic materials (plaster cast at the legs, cervical collar at the neck) The more the probe has small footprint, the less these obstacles Confusions with other structures Real structures: Lymph nodes, cysts, and hematomas Ghosts Limitations in the interpretation A nonthrombosed vein can mean a no longer thrombosed vein Other hindrances A compression on a painful area Here, on occasion, Doppler may be of interest Some Main Points for Concluding The search in extreme emergency of a venous thrombosis is a raison d’être of the BLUE-protocol The described equipment (one small unit with immediate switch-on, one unique probe) allows a scanning Our multipurpose probe is probably the most precious tool, since it can explore any area (lung, heart, vein, belly, etc.) The simple analysis of the venous content can be sufficient; the compression is done if there is no visible DVT and with minimal pressure Doppler is not mandatory Simple approaches can be described at any area, including popliteal, calf, and superior caval vein Large venous thromboses are easily detected, until the moment they are suddenly no longer visible Finding a small distal DVT has major relevance when massive pulmonary embolism is suspected Simple venous ultrasound should be recognized the gold standard Accessory Notes Timing This average timing of 55 s comes from these data: 10 s necessary for 1/4 of patients (positive examination at common femoral vein) 25 s for 1/4 (V-point) 65 s for 1/5 (calf) 85 s in roughly % (jugular/subclavian) 95 s in roughly % (middle femur) 115 s in roughly % (poplitea) 120 s in 1/5 of patients with negative venous test Anterior tibial veins The BLUE-protocol simplifies by not considering the anterior group (supposedly not emboligenic by the way), although usually easy to detect, just anterior to the interosseous membrane and just smaller (see Video 18.2) Sophisticated Notes Vein or artery? We open to a theoretical situation, which may be seen from time to time in a carrier When examining a patient with a pulmonary embolism plus a shock plus a thrombosed low femoral vein, the compression maneuver may collapse the artery (if the pressure is superior to the arterial pressure) and not the vein Stricto sensu, this may make a falsenegative Apart from a subtle sign (the collapsed artery will show systolic saccades) and hoping that the patient will not, precisely, have a bilateral, symmetrical pattern, the simplest clue is a comparative view, allowing to locate the vein (if a left low femoral vein is outside, the right low femoral vein will also be outside) References Anecdotal Notes How to transform a microconvex probe in superficial, “vascular” probe See Fig 31.4 which shows, from the mm to 17 cm range of our probe, how to see even the first mm, for one dollar (cheaper than buying a vascular probe) Perverse effects of Doppler The non use of Doppler today, when quite all machines are equipped, may appear futile There is a section in Chap 37 explaining in which perverse way Doppler was, indirectly, responsible for deaths In a few words: a high cost, preventing the purchase of machines which, simpler, would have made simple life-saving diagnoses, at a period where doctors were not informed of the power of simple ultrasound Craze for Doppler When we ask physicians why they need Doppler, we are surprised by the number of reasons, different from physician to physician One of the most popular, “it helps for recognizing the vein from the artery.” This distinction is of high simplicity It is nearly as immediate as recognizing a cat from a small dog (see Fig 3.2) References Davidson BL, Elliott CG, Lensing AW (1992) Low accuracy of color Doppler ultrasound in the detection of proximal leg vein thrombosis in asymptomatic high-risk patients The RD Heparin Arthroplasty Group Ann Intern Med 117(9):735–738 Cronan JJ (1993) Venous thromboembolic disease: the role of ultrasound, state of the art Radiology 186:619–630 Lichtenstein D, Jardin F (1997) Diagnosis of internal jugular vein thrombosis Intensive Care Med 23: 1188–1190 Lensing AWA, Doris CI, McGrath FP et al (1997) A comparison of compression ultrasound with color 141 Scientifical assessment of the pressure during compression We used utensils for calculating pressures and estimated wisely (and sufficiently) to limit pressure to the reasonable value of 0.5–1 kg/cm2 for keeping ultrasound a noninvasive tool Smiling ads for the pocket machines We often see advertisements of some pocket machines, with a group of enthusiastic young doctors showing a large smile, one hand holding the probe, the other holding the screen We agree, it is good to have a positive mind and to be always enthusiastic, but we consider that the instrument “critical ultrasound” should be “played” seriously with two hands Why this textbook Instead of trying to publish 1000 details, i.e., 5000 submissions, and one success per year, we prefer to write one unique book Not peer reviewed, just our 26-year observations The Grotowski law This law speculates that a non-critically ill patient who has a slight suspicion of embolism, and no thrombosis detected using our simple method, including the calf area in at least one point, is not at risk of sudden death See all details in Chap 36, section on pulmonary embolism Doppler ultrasound for the diagnosis of symptomless postoperative deep vein thrombosis Arch Intern Med 157:765–768 Bernardi E, Camporese G, Bueller H, Siragusa S, Imberti D, Berchio A et al (2008) Serial two-point ultrasonography plus D-dimer vs whole-leg colorcoded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis A randomized controlled trial JAMA 300(14): 1653–1659 Perlin SJ (1992) Pulmonary embolism during compression ultrasound of the lower extremity Radiology 184:165–166 Lichtenstein D, Mezière G (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure The BLUE-protocol Chest 134:117–125 142 18 The BLUE-Protocol, Venous Part: Deep Venous Thrombosis in the Critically Ill Alpert JS, Smith R, Carlson J, Ockene IS, Dexter L, Dalen JE (1976) Mortality in patients treated for pulmonary embolism JAMA 236:1477–1480 Moser KM, LeMoine JR (1981) Is embolic risk conditioned by location of deep venous thrombosis? Ann Intern Med 94:439–444 10 Appelman PT, De Jong TE, Lampmann LE (1987) Deep venous thrombosis of the leg: ultrasound findings Radiology 163:743–746 11 Cronan JJ, Dorfman GS, Grusmark J (1988) Lowerextremity deep venous thrombosis: further experience with and refinements of ultrasound assessment Radiology 168:101–107 12 Meibers DJ, Baldridge ED, Ruoff BA, Karkow WS, Cranley JJ (1988) The significance of calf muscle venous thrombosis J Vasc Surg 12:143–149 13 Philbrick JT, Becker DM (1988) Calf deep venous thrombosis: a wolf in sheep’s clothing? Arch Intern Med 148:2131–2138 14 Browse NL, Thomas ML (1974) Source of non-lethal pulmonary emboli Lancet 1(7851):258–259 15 De Weese JA (1978) Ilio-femoral venous thrombectomy In: Bergan JJ, Yao ST (eds) Venous problems Mosby Year Book, St Louis, pp 423–433 16 Mavor GE, Galloway JMD (1969) Iliofemoral venous thrombosis: pathological considerations and surgical management Br J Surg 56:45–59 17 Yucel EK, Fisher JS, Egglin TK, Geller SC, Waltman AC (1991) Isolated calf venous thrombosis: diagnosis with compression ultrasound Radiology 179: 443–446 Simple Emergency Cardiac Sonography: A New Application Integrating Lung Ultrasound 19 The heart, this organ that prevents us to examine the lung… Ph Biderman (December 26, 2007) We use the best of our 1992 Edition, Chap 20 (the heart), born from the privilege of having been working in echocardiography in a pioneering institution [1], a typical spirit of intensive care, a discipline aiming at reaching its autonomy Even if they have the feeling to master the heart, readers would find interest in understanding the spirit of this chapter The heart is a perfect example for holistic ultrasound Simple signs, a simple technique and, mostly, its association with LUCI define a new field, fully distinct from traditional echocardiography (even the one devoted to the critically ill) The consideration of the BLUEprotocol and the FALLS-protocol will allow to position our simple emergency cardiac sonography between the traditional basic and expert echocardiography, aiming at making this traditional separation less necessary Without lung ultrasound, the simple emergency cardiac sonography as defined would be insufficient Therefore, this chapter will be fully understood only if integrated in the following chapters Obviously, prestigious works on expert echocardiography Doppler are numerous They come from cardiologic fields [2], pioneering intensive care fields [1], many honorable sources [3], recent trends [4, 5], and so many sources that we can cite just a few, humbly apologizing for our lack of space [6–11] This chapter will be poor in references, many hemodynamic references being inserted in Chap 30 on the FALLS-protocol We use the simple emergency cardiac sonography since 1985/1989 and wrote the devoted chapter in 1992 (with no need for acronym; it was not a fashion in 1992, nor necessary) The basic echocardiography was popularized under several names, some rather elegant (the dynamic RACE of McLean, the FEER [12], FATE [13], etc., all now obsolete in the name of the recent FOCUS) [14] This shows that, beyond the war of acronyms, the community took interest in this concept For taking the best of our approach, experts must understand that we deal with the very first minutes of management, when critical actions have to be done The term “sonography” on the title was chosen on purpose: for most, “Echo” means traditional Doppler echocardiography, while “ultrasound” (please note the lowercase) means traditional abdominal examination by a radiologist Cardiology and radiology are two different worlds Critical care is a completely distinct world, with its own logic The main protocols of LUCI (BLUE-protocol, FALLS-protocol, and SESAME-protocol) are fully cardiac centered This is obvious for the FALLS-protocol, which begins by the heart, and the SESAME-protocol by essence (cardiac arrest) The BLUE-protocol aims at helping precisely when cardiac windows are lacking, another mark of interest We just consider the heart as a vital organ like another, and this respect must be shared with other vital organs D.A Lichtenstein, Lung Ultrasound in the Critically Ill: The BLUE Protocol, DOI 10.1007/978-3-319-15371-1_19, © Springer International Publishing Switzerland 2016 143 144 19 Simple Emergency Cardiac Sonography: A New Application Integrating Lung Ultrasound Our concept evolves as far as our main articles were published We aim at providing a textbook increasingly complementary to the echocardiography textbooks Consequently, from edition to edition (1992, 2002, 2005, 2010, etc.), the place of the heart, rather long in our first one (26 figures), is now limited to its essentials Daily concerns in critical care are mainly acute respiratory failure, acute circulatory failure, and cardiac arrest The habit of looking at the heart in case of lung disease can be questioned: a lung approach is more direct In the case of a circulatory failure, the FALLS-protocol shows that when one bases all of one’s calculations on the analysis of only one actor (the heart), this approach is direct only when the cause of shock is cardiac (what in passing the BLUE-protocol also detects using the lung approach) Adding the lung allows to keep the best of the simple heart The amount of information “lost” in terms of Doppler or transesophageal echocardiography will possibly be compensated using precious data that lung ultrasound provides, mainly a direct parameter of clinical volemia So Still No Doppler in The Present Edition? Dealing with echocardiography without mentioning Doppler or transesophageal approaches may appear bold today Having accrued experience in a pioneering institution in echocardiography in the ICU since 1989 [1], the authors came to the temptive conclusion that therapeutic procedures can be deduced from the observation of simple phenomena The integration of the lung gives birth to a new, holistic approach The reader will therefore not take offense if TEE and Doppler not feature Sophisticated echocardiography has a huge place in more quiet settings Topics and terms such as Doppler physics, measurements of stroke volume and cardiac output, assessment of LV and RV function, measurement of filling pressures and of diastolic function, evaluation of valve function, determination of preload sensitivity and of intracardiac pressures, and identification of adverse subtle flow interactions, none of these terms is dealt with at the CEURF courses: LUCI allows to simplify echocardiography and provide a simple unit, easy to purchase everywhere, using the same single probe; this is, again, holistic ultrasound The reader must understand that during as long as necessary, the DIAFORA approach will be used Here, a variant of DIAFORA will be used, “from inside,” i.e., by regular members of the ICU trained to echocardiography We write and will repeat at the end that the ideal combination in any modern ICU is a comprehensive unit able of all cardiologic measurements and, beside, our simple unit as defined This unit can be complementary in many settings to the usual cardiological approaches (read quietly Chaps 20 and 30) Do not forget that the expert echocardiographic approach is not an option for most patients on Earth Most figures come from a 1982 technology (ADR-4000®) Most figures of our previous editions have been deleted (see our 2010 Edition, or any classical echocardiography textbook) The life-saving diagnoses made using the simple cardiac sonography can be made without compromise using our 5-MHz microconvex probe and our slim gray-scale machine At the Onset, Two Basic Questions We raise two questions about cardiac sonography How to see the heart is modestly described in this chapter (we don’t aim to teach a lot to experts) Today, the critical care physicians know where the right ventricle is, what is a dilated right ventricle, etc Why we want to see the heart is a more critical question, which should be answered in light of the emergence of lung ultrasound As regards respiratory failure, this basic question will receive an answer in the BLUE-protocol (next chapter), showing that the diagnosis of The Signs of Simple Emergency Cardiac Sonography Used in the FALLS-Protocol: What Is Required? pulmonary edema pertains to lung ultrasound Facing circulatory failure, Chap 30 will show that the look to the heart is indirect each time the cause is not cardiac In the FALLSprotocol, after a simplified cardiac approach, lung ultrasound provides a direct parameter for fluid therapy As regards cardiac arrest, the heart will come fifth in the SESAME-protocol (Chap 31) The Signs of Simple Emergency Cardiac Sonography Used in the BLUE-Protocol: What Is Required? Nothing, since the BLUE-protocol uses lung and venous data Echocardiographic data are associated to it, not included LUCI provides a 97% sensitivity for diagnosing hemodynamic pulmonary edema The Extended BLUE-protocol adds points using simple cardiac data The Signs of Simple Emergency Cardiac Sonography Used in the FALLS-Protocol: What Is Required? The acute circulatory failure benefits first from a clinical examination, which usually provides a correct diagnosis When no cause appears, the FALLS-protocol is initiated It begins by the heart This exploration is limited to two items: pericardial effusion and dilated right ventricle We therefore need to know which machine to use, which probe, where to apply the probe, how to understand the structures, and how to recognize the anomalies The CEURF spirit will be used for simplifying this part Which Machine? We use the same gray-scale unit used for the lungs, veins, abdomen, optic nerve, etc., a 1992 technology described in Chap 145 Which Probe? We use the same probe used for the lungs, veins, abdomen, optic nerve, etc., a 1992 Japanese technology described in Chap Where to Apply the Probe? Traditional windows (parasternal, apical, subcostal, etc.) have been carefully defined It is assumed today that intensivists, emergency physicians, etc., control these windows (see Appendix 1) Holistic ultrasound integrates them, but proposes an immediate, pragmatic solution when the windows are not perfect The readers will see that the SESAMEprotocol (Chap 31) begins by the lung for the main reason that the fear not to find correct windows is absent from this first step As a critical detail, we not spend high energy for having perfect cardiac windows, because we are not cardiologists, especially those working for other physicians (or even sonographists, who master this art) In the same way that you recognize a familiar face at first sight even if not strictly face/profile, you recognize the cardiac chambers This critical detail makes simple cardiac sonography fully different to traditional echocardiography The subcostal approach, very appreciated by intensivists in ventilated patients since often the only available, follows this philosophy: it offers a cardiac view of major interest even if truncated (Fig 19.1) The apical approach gives at last the feeling that the heart, a complex organ, has a simple anatomy, since the ventricles are anterior (the auricles posterior) and the left chambers are at the right (the right chambers at the left) For once, things seem symmetrical (Fig 19.2) Countless details can help when windows are lacking Wait for end-expiration to have a brief look to the heart In the subcostal route, taking some liver tissue can increase cardiac image quality The right parasternal route can show dilated right structures When nothing works, the lung will answer many questions 146 19 Simple Emergency Cardiac Sonography: A New Application Integrating Lung Ultrasound How to Understand the Structures? Fig 19.1 Subcostal view of the heart This approach is a classic in the intensive care unit It is a truncated equivalent of the four-chamber apical view of Fig 19.2 RV right ventricle, RA right auricle, LV left ventricle, LA left auricle The operator should move the probe from top to bottom (Carmen maneuver in fact) to acquire a correct three-dimensional representation of the volumes The pericardium is virtual here The anatomy of the heart is complex Those who will compare it to the rather simple ultrasound of the anatomy of the lung (just two signs) will make a step toward holistic ultrasound (the next step is to learn how far lung ultrasound answers to “cardiac questions”) Any echocardiographic textbook or costly simulators will show the cardiac structures Ultrasound is a good way to understand, noninvasively, this anatomy Normal cardiac anatomy in 20 lines The left ventricle is ovoid shaped, with a thick muscle and a long axis pointing leftward, downward, and forward It has a base (where the aorta and, deeper, the left auricle are inserted), an apex, and four walls: inferior, lateral, anterior, and septal The right ventricle has a more complex anatomy and is wounded around the left ventricle, with a thin free wall and a thick septal wall Its volume assessment is subtle (due to its complex shape, novices taking a wrong plane will imagine enlargement where there is no enlargement) Its apex covers the septum; its base (infundibulum) covers the initial aorta The main intracavitary structures are the valves and the left ventricular pillars The auricles are visible behind the ventricles, yet, since we are not cardiologists, they are rarely of interest The cardiac muscle is echoic The chambers are anechoic The pericardium is virtual Which Measurements? In the spirit of simple emergency cardiac sonography, measurements are not of prime relevance In addition, most intensivists have now been trained and know them Read Appendix Simple cardiac sonography is based on visual medicine Fig 19.2 Four-chamber view, apical window Here, the heart seems to be a symmetric structure LV left ventricle, LA left auricle, RV right ventricle, RA right auricle This incidence allows immediate comparison of the volume and dynamics of each chamber Note that the plane of the tricuspid valve is more anterior than the plane of the mitral valve Right auricle and left ventricle are in contact (arrow), a detail which allows correct orientation How to Identify Cardiac Anomalies Pertaining to the FALLS-Protocol? Pericardial Fluid This is one of the most basic applications of critical ultrasound It is life-threatening, easy to diagnose, and easy to treat A circumferential The Signs of Simple Emergency Cardiac Sonography Used in the FALLS-Protocol: What Is Required? Fig 19.3 Fluid collection in the pericardial space The septations indicate an infectious cause Note that the effusion (E) surrounds the entire heart: it is visible anterior to the left ventricle in this subcostal approach (smaller E) Pleuropericarditis due to pneumococcus pericardial effusion is detected when the external border of the heart is outlined by another, larger, external border, it is really simple to assess (Fig 19.3) An equivalent of the sinusoid sign is found between the parietal and visceral layers of the pericardial sac during cardiac contractions Usually anechoic, fluids can be echoic, septated (hemopericardium, purulent pericarditis) (Fig 19.3), etc., and we avoid to define a pericardial effusion as an anechoic space, exactly like pleural effusions in the BLUE-protocol In exceptional cases, usually postoperative, loculated effusions can threaten the circulation if located on strategic areas Pericardial fat is usually limited anteriorly, echoic, and devoid of sinusoid dynamics The FALLS-protocol defines as pericardial tamponade any substantial pericardial fluid seen in a patient with an acute circulatory failure The real-time analysis of the right cavities, showing chamber collapsus, dramatically increases this likeliness The sign of the dancing heart, not used in the FALLS-protocol, is easy to diagnose For other signs, see Appendix and Video 31.1 Our personal technique of pericardiocentesis is dealt with in Chap 31 Right Ventricle (RV) Volume There are two reasons to look at the RV in the FALLS-protocol 147 Fig 19.4 Massive pulmonary embolism Major dilatation of the right ventricle (RV) in a four-chamber view using the apical route LV, left ventricle Mainly, for Detecting an Enlargement The RV normally works under a low-pressure system Any hindrance to RV ejection, as seen in severe pulmonary embolism, but also severe asthma, ARDS, extensive pneumonia will promptly generate its dilatation [15] Acute right heart failure associates early RV dilatation (Fig 19.4), a displacement of the septum to the left, a tricuspid regurgitation (see Video 30.2) The apical four-chamber view provides the most objective way to detect an RV dilatation, defined when its volume is the same as in the left ventricle or more When cardiac windows are poor, one can use instead either a transesophageal approach or the BLUE-protocol: the combination of an A-profile with a venous thrombosis in a patient seen for acute respiratory failure has a 99 % specificity for the diagnosis of pulmonary embolism [16] It will be seen that the BLUE-protocol works for blue patients; patients with ARDS are not blue (under full oxygen, sedation etc.), and different rules apply; see the CLOT-protocol in Chap 28 Pulmonary embolism is a field where everything has been said [17, 18] TEE sometimes provides a direct sign (clot in the pulmonary artery) However, the CEURF protocols have developed a way of optimizing this approach; read this section in Chap 31 Note that the place of Doppler (major here for years) gradually decreases, since the severity 148 19 Simple Emergency Cardiac Sonography: A New Application Integrating Lung Ultrasound of pulmonary embolism was correlated with the degree of obstruction, a data little correlated with pulmonary arterial pressure (not always elevated in severe cases of embolism) but better correlated with the RV volume (and the left/right ratio), i.e., a simple cardiac sonography [19] More Occasionally for Detecting a Volume Decrease More occasionally, for these reasons: • A small RV seen in hypovolemia would be redundant in the FALLS-protocol with the A-profile • A small RV within a substantial pericardial effusion, in a shocked patient, is quite redundant for the diagnosis of pericardial tamponade Yet since this is not the most difficult part of echocardiography, holistic ultrasound is fully opened to include this analysis The Signs of Simple Emergency Cardiac Sonography Used in Cardiac Arrest (the SESAME-Protocol) In the first seconds, tension pneumothorax (lung), pulmonary embolism (lung and veins), hypovolemia (abdomen, pleural cavity, etc.), then a pericardial tamponade (see above) are sought for The heart comes 5th Diagnoses of ventricular fibrillation, auriculoventricular block, etc., are sometimes obvious and sometimes subtle Asystole is a rather easy diagnosis, although of limited interest See Chap 31 Signs of Simple Emergency Cardiac Sonography Not Used in the BLUEProtocol, FALLS-Protocol, Nor SESAME-Protocol Chapter 30 (hemodynamic assessment of shock) does not insert basic signs such as the left ventricle contractility in the decision tree, but we admit it should be really strange not to use these basic, easy-to-learn signs Left Ventricle (LV) Overall Contractility How to measure it: the ejection fraction is the most academic and is not described here The shortening fraction, a basic measurement easy to obtain, is sufficient for having a diagnosis in critical settings With a little experience, one can classify without any measurement a hypocontractile, normocontractile, and hypercontractile LV, what we since 1990 and what was fortunately recently admitted The diagnosis of a LV hypocontractility is done by detecting a decrease in the amplitude of muscle shortening (Appendix 2) Why to measure it: LV hypocontractility in a shocked patient is due to cardiogenic shock, basically, and can be seen in septic shock (recent data suggest that all patients in septic shock develop the septic cardiomyopathy, more or less occult, depending on post-charge and other parameters) [20] The first condition invites to inotropic support; the second suggests it with a call for confirmation An exaggerated contractility suggests that an inotropic option is not useful and that, according to the principle of the communicating vessels, the probability increases for the remaining options: vasopressors or fluids (in the FALLSprotocol, these options will be answered before the LV analysis, but the physician is free to the opposite) Echocardiography integrated within the BLUE-protocol will open to multiple subtleties For instance, an acute respiratory failure with no B-profile indicates a suffering of the right, not left, heart, with the theoretical exception (to be confirmed) of a major septal interference, impairing the left heart function The echocardiographic science has recently been complicated/enriched by the notion of diastolic dysfunction, which should be responsible for half of the cases of left heart failure (until new articles balance these data) Read below Hypovolemic Shock It typically shows hypercontractile LV, small end-diastolic cavity, and sometimes virtual endsystolic volume (Fig 19.5) This approach is not A Preview of More Complex Cardiac Applications Fig 19.5 Profile of possible hypovolemia Hypercontractile pattern of the left ventricle M-mode acquisition in a shortaxis parasternal view Small diastolic chamber Quasi-virtual systolic chamber Tachycardia This shocked patient had abdominal sepsis The hypovolemia is probable since the further images improved (contractility, size, frequency) – in a patient who had by the way the A-profile used in the CEURF protocols (read Chap 30 or a summary in Anecdotal Note 1) Dilated Cardiomyopathy One just has to appreciate the size of the chambers Hypertrophic Cardiomyopathy One just has to appreciate the thickness of the walls Chronic Right Heart Insufficiency One has just to measure the free wall of the RV, thickened in the case of a chronic obstacle, as seen in COPD (Fig 19.6) A Preview of More Complex Cardiac Applications Which Are Not Used in Our Protocols and Rarely in Our Daily Clinical Practice This is just a preview, unless this section would (a bit) look like any echocardiographic textbook 149 Fig 19.6 Exacerbation of chronic right heart failure Major right ventricle dilatation Note the squashed left ventricle, and the substantial thickening of the free wall of the right ventricle Short-axis parasternal view Diastolic Ventricular Dysfunction We will not pretend to have the slightest expertise in this field Just an observation from a distance allows us to see, as usual, two opinions Some tell it is an easy field, well mastered [21]; others consider it as a whole science of illimited complications (private talks with Michèle Desruennes) Its frequency is variable according to the schools The philosophy of simple emergency cardiac sonography uses a simple, accessible data, the hypertrophy of the LV walls (Fig 19.7), and asks the question: doesn’t it provide already an interesting piece of information (not arguing to solve the problem from A to Z)? A thickened LV, even with a preserved contraction, or an enlarged left auricle should alert for a diastolic anomaly (free talks from Drs McLean and Voga) We will mostly use the help of lung ultrasound, because it would show early signs of left heart dysfunction (whatever the cause: systolic, diastolic) The BLUE-protocol begins by searching signs of pulmonary edema, i.e., the B-profile No B-profile? No LV diastolic dysfunction Myocardial Infarction Ultrasound must be a tool, not a disease ECG data allow usual diagnoses, although some advocate that ultrasound anomalies are visible early, thus modifying immediate management [22] The 150 19 Simple Emergency Cardiac Sonography: A New Application Integrating Lung Ultrasound Fig 19.7 LV hypertrophy The parietal LV thickness is 16 mm A parietal shock was perceived, synchronized with the auricle systole, probably indicating a sudden increase in pressure in a chamber whose volume could not increase Long-axis parasternal view Note the image quality of this 1982 portable technology Note: we took the liberty of using radiological conventions, i.e., head to the left, feet to the right This is probably the only detail we borrowed from the radiological culture subtle diagnosis of segmental anomalies requires expertise Right ventricle dilatation suggests right ventricle infarction One advantage of critical ultrasound is to immediately rule out other diagnoses of thoracic pain (pericarditis, pneumothorax, pneumonia, aortic dissection, etc.) Endocarditis Some words about this diagnosis First, its rarity is a typical indication to our opinion for the DIAFORA approach, while several blood cultures are performed There is no space for arguing that TEE should be the gold standard This also regards cases on metallic valves However, our experience showed that in many cases, real-time imaging with a good resolution probe (such as our microconvex one) shows “something.” This change is usually clear enough (Fig 19.8) Instead of the regular, thin valvular pattern, a pathological image is seen, thicker, irregular, with hectic dynamics, echoic like a tissue, and larger at the end of the valve A calcification is recognized through its Fig 19.8 Endocarditis Tissue-like mass depending on the tricuspid valve A diagnosis of endocarditis in a young drug addict was immediately made using this subcostal ultrasound view, quickly confirmed by positive blood cultures (staphylococcus) M vegetation hyperechoic superficial pattern and its anechoic acoustic shadow Valvular Diseases Valvular diseases, issues with mechanical valves, some mechanical complications of myocardial infarction, septal rupture, and hypertrophic asymmetric cardiomyopathies would be beyond the scope of this book Specialized techniques such as transesophageal Doppler echocardiography, used by specialists, will here provide the best approach [23] Like endocarditis, in very echoic patients, overt mitral valve anomalies can be detected (mitral valve prolapse, valvular thickening, etc., diagnosed for cheap without Doppler) Intracavitary Thrombosis, Tumor, and Device Intracardiac thromboses (Fig 19.9) show scary images of echoic patterns, sometimes mobile, of high specificity For the sensitivity, transesophageal approach should give better results (if a simple approach did not answer) Right ventricle normal structures (e.g., papillary muscle) are not thromboses Before Concluding: How to Practice Emergency Echocardiography When There Is No Cardiac Window 151 Gas Embolism It yields large, hyperechoic echoes, highly dynamic, with posterior shadow (see Fig 22.20 of our 2010 Edition) In a supine patient, these gas bubbles transiently collect at the anterior part of the right ventricle and travel little by little in the pulmonary artery – unless the patient is promptly turned to the left lateral position Gas embolism complicating the central venous line insertion can be predicted (see Chap 34) Fig 19.9 Left ventricular thrombosis Substantial thrombosis (M) at the apex of the left ventricle Subcostal view Tumors are so rare that we not develop this field: make DIAFORA instead A too long distal end of a catheter should be searched for in the right chambers, acoustic window permitting Interesting was the ability to check, in real time, the progression of the SwanGanz catheter through the vena cava, auricle, ventricle, pulmonary artery, etc See Figure 22.23 of our 2010 Edition One operator inserted the material; the other guided the distal end of the catheter using the subcostal approach Asepsis could be efficiently controlled This was around 1991–1993, then we asked, why have an ultrasound probe in hand and perform anyway a cardiac catheterization? The position of a electrosystolic probe can be checked in the right ventricle Gas Tamponade This is typical When cardiac chambers are collapsed by massive gas under tension, instead of spending energy for trying to have the cardiac windows (quite always not accessible), our approach is to see rather the lungs, detecting immediately the (sometimes bilateral) pneumothorax We will see that in shock (FALLSprotocol), this search comes third and, in cardiac arrest, it comes first Anecdotal Diagnoses Many can be described here, but their exhaustive description would overburden this book Let us just cite this severe shock with pulmonary edema due to an esophageal abscess squashing the left auricle, making the conditions for septic shock plus cardiogenic shock by compromised pulmonary venous return (see Fig 22.25 in our 2010 Edition) This young lady had the correct diagnosis, mostly thanks to TEE Before Concluding: How to Practice Emergency Echocardiography When There Is No Cardiac Window One aim of this textbook is to develop solutions, to be considered in extreme emergencies The BLUE-protocol was designed for assessing the origin of a respiratory failure The FALLS-protocol can be used [24], since the first step (cardiac) can be simplified: pericardial tamponade usually provides windows, and pulmonary embolism can be detected most of the time using the BLUE-protocol How to assess the cardiac overall contractility may be solved using, once again, lung ultrasound: the lung pulse, detailed in Chaps 10 and 35, may be a sign of good contractility (to be confirmed using carefully designed studies) 152 19 Simple Emergency Cardiac Sonography: A New Application Integrating Lung Ultrasound Repeated as Previously Announced, Our Take-Home Message We have no willingness to replace traditional TTE or TEE This would not be scientific at all What we advocate, in any current ICU equipped with the up-to-date Doppler echocardiographic unit which makes “all,” is, besides, a modest black-and-white unit with a single probe, easy to buy, for making “the rest.” Our vision of the “rest” is modestly defined in this textbook What we bet is that at the beginning, the simple machine will be used from time to time (e.g., check for empty bladder) Then, increasingly, control coming, the simple unit will be used for hundred daily tasks (e.g., subclavian vein cannulation) Time running, the simple unit will then make shy attempts in echocardiography (e.g., checking for absence of pericardial tamponade), then with more assurance (e.g., associating hypercontractile left heart with an A-profile for suggesting a clearance for fluid therapy) At one more step of evolution, the simple unit will be used as often as the comprehensive, cardiac one (a victory of holistic ultrasound) Appendix Heart Routes The left parasternal route is, as labelled, the left parasternal area (2010 Ed, Fig 22.1) The apical route corresponds to the systolic shock The left positioning is not easy in a ventilated patient Mechanical ventilation often creates a hindrance to the transthoracic approach of the heart, and the subcostal route has been widely used in sedated supine patients This is an abdominal approach, with the probe applied just to the xiphoid, body of the probe applied almost parallel the abdominal wall Measurements Only rough estimates (some possibly obsolete) will be given In a short axis at the pillar level, the LV walls (septal or posterior) are 6–11 mm thick in diastole The LV chamber caliper is 38–56 mm The RV free wall is less than mm thick A precise measurement of the RV volume should include subtle criteria, since its shape is complex An M-mode image through the LV small axis can measure (2010 Ed, Fig 22.8) the LV chamber dimension in diastole, which indicates a dilatation, and this dimension in systole, which defines contractility The difference of these two values, divided by the diastolic dimension, defines the LV shortening fraction, a parameter of the ventricular systolic function It is normally 28–38 % The parietal thickening fraction (the ratio of the difference of diastolic and systolic thickening over diastolic thickening, normal range from 50 to 100 %) is less useful in our day (and above all night) routine Pericardial Tamponade Some signs in concert with cardiac and respiratory cycles can be observed, in spontaneously breathing patients Inspiration facilitates venous return, and the right ventricle dilates at the expense of the septum, which is more compliant than the free wall The septum is shifted to the left and compresses the left ventricular chamber Diastole creates a decrease in intracavitary pressures, whereas intrapericardial pressure remains constant The right chambers are thus collapsed by the surrounding pressure The right auricle wall collapses first, then the right ventricle The description of signs using Doppler would have a beneficial effect: showing physiopathologic patterns It may also complicate the design, if time is wasted, if too sophisticated units are used, and if the operator is not trained enough References Anecdotal Note Hypovolemia Traditionally, for diagnosing hypovolemia in a shocked patient, the heart is the main target (with Doppler and TEE) This textbook focuses at the lung – especially in extreme emergency and/or if no cardiac window is available In the FALLSprotocol and SESAME-protocol, hypovolemia is defined by an A-profile (associated if possible with the ultrasound detection of massive free fluid) References Jardin F, Farcot JC, Boisante L, Curien N, Margairaz A, Bourdarias JP (1981) Influence of positive endexpiratory pressure on left ventricle performance N Engl J Med 304(7):387–392 Braunwald E (1992) Heart disease Saunders, Philadelphia Benjamin E, Oropello JM, Stein JS (1996) Transesophageal echocardiography in the management of the critically ill patient Curr Surg 53:137–141 Vignon P, Goarin JP (2002) EchocardiographieDoppler en réanimation, anesthésie et médecine d’urgence Elsevier, Amsterdam Diebold B (1990) Intérêt de l’échocardiographie Doppler en réanimation Réan Soins Int Med Urg 6:501–507 Vieillard-Baron A, Charron C, Jardin F (2006) Lung “recruitment” or lung overinflation maneuvers? Intensive Care Med 32:177–178 Price S, Nicol E, Gibson DG, Evans TW (2006) Echocardiography in the critically ill: current and potential roles Intensive Care Med 32:48–59 Vieillard-Baron A, Slama M, Cholley B, Janvier G, Vignon P (2008) Echocardiography in the intensive care unit : from evolution to revolution ? Intensive Care Med 34(2):243–249, Epub 2007 Nov Review Vieillard-Baron A (2009) Assessment of right ventricular function Curr Opin Crit Care 15(3):254–260 doi:10.1097/MCC.0b013e32832b70c9, Review 153 10 Jardin F, Vieillard-Baron A (2009) Acute cor pulmonale Curr Opin Crit Care 15(1):67–70, Review 11 Vieillard-Baron A (2009) Is right ventricular function the one that matters in ARDS patients ? Definitely yes Intensive Care Med 35(1):4–6 12 Breitkreutz R, Walcher F, Seeger FH (2007) Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm Crit Care Med 35:S150–S161 13 Sloth E (2006) Echocardiography in the ICU Intensive Care Med 32:1283 14 Via G, Hussain A, Wells M, Reardon R, ElBarbary M, Noble V, Tsung JW, Neskovic AN, Price S et al (2014) International evidence-based recommendations for focused cardiac ultrasound J Am Soc Echocardiogr 27(7):683.e1–683.e33 doi:10.1016/j echo.2014.05.001 15 Jardin F, Dubourg O (1986) L’exploration échocardiographique en médecine d’urgence Masson, Paris 16 Lichtenstein D, Mezière G (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure The BLUE-protocol Chest 134:117–125 17 Goldhaber SZ (2002) Echocardiography in the management of pulmonary embolism Ann Intern Med 136:691–700 18 Schmidt GA (1998) Pulmonary embolic disorders In: Hall JB, Schmidt GA, Wood LDH (eds) Principles of critical care, 2nd edn McGraw Hill, New York, pp 427–449 19 Jardin F (2009) Acute cor pulmonale Curr Opin Crit Care 15(1) 20 Vieillard-Baron A, Cecconi M (2014) Understanding cardiac failure in sepsis Intensive Care Med 40(10): 1560–1563 21 Saleh M, Vieillard-Baron A (2012) On the role of left ventricular diastolic function in the critically ill patient (Editorial) Intensive Care Med 38: 189–191 22 Horowitz RS, Morganroth J, Parrotto C, Chen CC, Soffer J, Pauletto FJ (1982) Immediate diagnosis of acute myocardial infarction by two-dimensional echocardiography Circulation 65:323 23 Vignon P, Mentec H, Terré S, Gastinne H, Guéret P, Lemaire F (1994) Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU Chest 106:1829–1834 24 Lichtenstein D (2013) FALLS-protocol: lung ultrasound in hemodynamic assessment of shock Heart Lung Vessel 5(3):142–147 ... 17 8 17 9 17 9 17 9 18 1 18 1 18 1 18 1 18 2 18 2 18 2 18 4 18 5 18 5 18 7 18 7 18 7 18 7 18 7 18 8 18 8 18 8 18 8 18 9 18 9 18 9 19 0 19 1 19 1 19 1 19 3 19 3 Contents xv 27 BLUE-Protocol and... Value of the BLUE-Protocol for Ruling Out Other Diseases 16 5 16 5 16 5 16 6 16 7 16 7 16 8 16 8 16 9 17 1 17 1 17 2 17 2 17 3 17 3 17 3 17 3 17 3 17 3 17 4 17 4 17 4 17 4 17 4 17 5 17 5 17 5 17 7 17 7 17 7 17 7 17 8 Contents... 11 4 11 5 11 5 11 6 11 7 11 7 11 8 11 8 11 8 12 0 12 1 12 1 12 1 12 2 12 3 12 3 12 3 12 3 Contents xii To Who Can This Chapter Provide New Information? The Developed BLUE-protocol